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ApplicationsWill Be Processed When Submitted Properly Completed. BeSure To Sign The A <br /> FOR oFF�cE usE: APPLICATION Ppiication, <br /> (For Non-Transferable, Revocable, Suspendable) <br /> t�� <br /> ENViRONMENTAL HEALTH PERMIT RUMP&WE <br /> cr (COMPLETE IN TRIPL "ATE) WATER QUALITY <br /> Application is hereby rn(de to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This-op <br /> . l' s <br /> made in compliance with San Joaquin County Ordinance No. 7862 and the rule an r -+pp Ication is <br /> Exact Site Address ap ogulatlons of the San q in Local Health District. - <br /> [ ]'Town {x <br /> f Owner's Name <br /> Address Phone Xa� <br /> E Contractor's Name _ City_ <br /> Contractor's Address sn?��y� License# 24AZ <br /> Business Phone_ <br /> Is Certificate of Workmen's Compensation I e o I h mergency Phone � -- <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN Q Yes_ / No <br /> WELL CHLORINATION ❑ RECflNDITIDN❑ ❑ESTRUCTION❑ f <br /> WELL DEEPEN <br /> ❑ OTHER ❑REPLACEMENT 0 PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines_ Pit Privy — <br /> Sewage Disposal Field _ ` Cesspool/Seepage Pit y <br /> Property Line Private Domestic Well - Other <br /> INTENDED USE Public Domestic Well <br /> � _ <br /> ❑ INDUSTRIAL TYPE OF WELL ` <br /> XDOMESTIC/PRIVATE CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PUBLIC ❑ DRILLED Dia. of Well Casing <br /> ❑ IRRIGATION ❑ DRIVEN Gauge of Casing _ f �El CATHODIC PROTECTION �ROTARYR <br /> - <br /> GRAVEL PACT{ Depth of Grout Seal , <br /> d DISPOSAL ❑ Type of Grout <br /> OTHE <br /> ❑ GEOPHYSICAL — — — Other Information <br /> PUMP INSTALLATION: Surface Seal Installed By: <br /> Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: _ — — <br /> ❑ State Work Done_ - Fi.P- <br /> PUMP REPAIR; El State Work Done <br /> DESTRUCTION OP WELL: L <br /> Well Diameter_ — <br /> Describe Material and Procedure_ Approximate Depth ` <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules arid regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws Of California-" f <br /> Contractors hiring or sub-contracting signature certifies•the following:"!certify that in the performance of the work forwhich this <br /> ti permit is issued. I shall employ persons subject to workman's compensation laws of California:' <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> d f <br /> Signed X _ �r J <br /> { f! itle: _ Date: <br /> [Dra+,v Pr tan on Reverse Sider <br /> FOR DEPARTMENT USE ONLY F <br /> ASE I .� 4 <br /> plication Accepted By `1, <br /> ditional Comments: _ Date <br /> 9e I Inspection Grout Inspection �~ _ <br /> By � Phase inal Inspection 10 <br /> �'� Date Inspection By 0 F <br /> Fee is Due:❑ ANNUALLY <br /> Date <br /> ❑ PER UNIT ❑ PEn SITE ❑ EA1CH ❑ Janus <br /> ry 1&-Rrcuivetl By January 31 ❑ JuIY 1&Received 8y July 31 <br /> SASE BILL)NG REM)TTANCF $ REMIT <br /> ❑ATE DATE REMITTED AMOUNT DUE CHECKFD <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHEFI w <br /> x-- 4 �� _ <br /> Received 6 -"`',Reccipt PE'+ <br /> ND. <br /> _ mlt Na. <br /> APPLICANT— 159llAnCe Date' <br /> RETURN ALL CeP1E3 TO:• EIIVIROHIREN7AL-HEALTH Mailed Delivered <br /> ��TISERYICES 1601 E.HAZELTON AVE.,P-O.Sax ZD09 <br /> STOCRTA1a to m• <br />